The other big culprit may be thiazides (water pills), usually used for high blood pressure, which may increase the risk of acute cholecystitis developing in a patient with gallstones (BMJ, 1984; 289: 654-655). Although gallstones rarely occur in children, they are more likely to develop after taking furosemide (J of Perinatology, 1992; 12 [2]: 107-111).

Despite the clear association with diet in most cases, medicine persists with a barbaric solution to gallbladder disease. In 1991, 600,000 people decided to "solve" the gallstone problem by having their gall bladder removed altogether (cholecystectomy). This can be done in two ways: either through traditional "open" surgery (open cholecystectomy, or minilaparotomy); or through keyhole (minimally invasive) surgery, where the gall bladder is literally pulled though a small incision in the abdomen. Endoscopic sphincteroscopy is commonly used to remove stones in the bile duct.

An open cholecystectomy may be required if a keyhole operation runs into trouble, and may be considered the treatment of choice for severe infection, perforation of the gall bladder or severe, acute cholecystitis.

However, the so called surgical alternatives carry with them their fair share of risk, which can aggravate the condition rather than cure it. Laparoscopy, or keyhole surgery, has attracted much publicity and criticism.

In the late eighties the modern era of laparoscopic surgery was ushered in when a miniature video camera was attached to the eyepiece of a laparoscope, so that the surgeon could operate via the video screen. Both doctors and patients immediately pressed for a revolution in keyhole gall bladder operations without a single clinical trial confirming its benefits (J Royal College Surg Edinburgh, 1993; 38: 353).

Since then, many surgeons have whipped out gallbladders using the technique, citing its advantages over an open cholecystectomy, or laparotomy patients experience much less pain, spend less time in hospital and recover much more quickly (Surg Endosc, 1989; 3: 131-3; Surg Gynecol Obstet, 1992; 174: 114-8).

However such claimed benefits have been disputed. For instance, a speedier return to work, where it happens, may be due to several influences; and social class, cultural factors, and even a patient's occupation also contribute to this highly variable outcome (Lancet, 1994; 343: 308-9; Am J Surg, 191; 161: 396-8).

As many as 80 per cent of cholecystectomies are now performed laparoscopically in the US (JAMA, 1993; 269: 1018-24 and 270: 1429-32).

However, the operation does have its risks, and the widespread adoption of laparoscopic cholecystectomy has aroused concern about how safe the new procedure really is (New Eng J of Med, 1994; 330: 403; WDDTY, vol 4, no 12). Studies carried out in Maryland hospitals between 1985 and 1992 show that the overall number of deaths has decreased by 33 per cent since keyhole gall bladder surgery was introduced. However, the total number of gall bladder related deaths has not fallen because of a 28 per cent increase in the total number of gallbladder operations being performed.

Thus, the attraction of "band aid" surgery has appeared simply to convince more patients to rush into an operative solution (New Eng J of Med, 1994; 330: 403; JAMA, 1994; 271: 500-1).

The supposed fall in the death rate also masks the dangers of the operation, and its technical difficulties. The success of an endoscopic sphincterotomy, for example, depends on the proper training, skills and experience of the endoscopist. A recent study found that complications can occur around 10 per cent of operations, including haemorrhage, pancreatitis inflammation of the pancreas, a potentially fatal condition perforation of the duodenal wall, and cholangitis being the most frequent (New Engl J Med, 1996; 335: 961). About one in a hundred patients can die from this kind of operation (Gastrointest Endosc, 1991; 37: 383-93).

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